Immune Thrombocytopenia (ITP)


Immune thrombocytopenia (ITP) is a condition characterized by a low platelet count, often below 100,000/μL, that is caused by the immune destruction of platelets. Patients also may present with generalized petechial rash, bruising, or variable bleeding symptoms.1,2

Bleeding Complications

Several complications affecting adults and children are associated with ITP. Most commonly, these complications derive from bleeding risk associated with low platelet count. This risk is higher when the platelet count decreases below 20,000/μL. Bleeding complications include gastrointestinal tract bleeding that may lead to heme-positive stools, hematuria, and menorrhagia.1 Other internal bleeding, such as subarachnoid hemorrhage, may occur.3 

Although mortality due to ITP is rare in children, it is mainly caused by complications following severe bleeding, such as intracranial hemorrhage (ICH).4 ICH is the most severe and rare complication seen in patients with ITP. The frequency of ICH in patients with ITP ranges from about 0.5% in children to 1.5% in adults.5 ICH usually occurs when platelet counts are below 10,000/μL, however, it can also occur following head trauma, severe bleeding, or the use of antiplatelet medication.1 Symptoms of ICH include headache, persistent vomiting, seizures, focal neurological findings, and altered mental status.4

Read more about ITP signs and symptoms

Postoperative Complications

The management of ITP may include splenectomy, which can carry potential risks or long-term complications. This surgical approach has been associated with an increased risk of infection and sepsis, a risk of thrombosis that is more than 30-fold higher than that of the general population, pulmonary hypertension, and immediate postoperative complications.2 These complications occur in 10% of patients, and death occurs in 0.2% of patients.6 

Long-term complications associated with splenectomies performed in patients with ITP have also been reported.2 In one study, 17% of the followed patients experienced early postoperative complications, including hemorrhage, infection, and venous thromboembolism (VTE). During the follow-up period, 16% of the patients presented with VTE. Bacterial infections were more common in patients undergoing surgery, and these infections more frequently lead to hospitalization.7 A different study involving 174 adult patients reported, however, a VTE rate of 2.9%.8 

Read more about ITP surgical management

Immune Thrombocytopenia and Pregnancy

Immune thrombocytopenia is estimated to affect 1 to 10 in 10,000 pregnancies, either as a primary condition or linked to an immune condition.2 About 30% of these cases require treatment. If properly managed, severe bleeding is not common with ITP. However, women with ITP who become pregnant may experience higher incidences of fetal loss and premature birth, as well as a lower birth weight for gestational age.2 These women can also develop other complications, such as preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.9 The risk of severe thrombocytopenia in the neonate may reach 30%.2

The recommended first-line therapy relies on intravenous immunoglobulin or corticosteroids, both of which carry mild toxicity for both the mother and fetus. These medications can lead to weight gain, hyperglycemia, and hypertension. Although the benefit may outweigh the risk, the therapy demands close monitoring throughout the pregnancy.2

A patient’s risk of complications deriving from the use of epidural catheters during delivery is related to their degree of thrombocytopenia and has been shown to be 0% to 0.6% when platelet counts are between 75 and 80 x 109/L. A 6.5% risk of complications has also been reported with the use of general anesthesia.2 

Read more about ITP treatment

References

1. Pietras NM, Pearson-Shaver AL. Immune thrombocytopenic purpura. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2022. Updated May 10, 2022. Accessed October 17, 2022.

2. Lambert MP, Gernsheimer TB. Clinical updates in adult immune thrombocytopenia. Blood. 2017;129(21):2829-2835. doi:10.1182/blood-2017-03-754119

3. Onisâi M, Vlădăreanu AM, Spînu A, Găman M, Bumbea H. Idiopathic thrombocytopenic purpura (ITP) – new era for an old disease. Rom J Intern Med. 2019;57(4):273-283. doi:10.2478/rjim-2019-0014

4. Neunert C, Noroozi N, Norman G, et al. Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review. J Thromb Haemost. 2015;13(3):457-464. doi:10.1111/jth.12813

5. Arnold DM. Bleeding complications in immune thrombocytopenia. Hematology Am Soc Hematol Educ Program. 2015;2015:237-242. doi:10.1182/asheducation-2015.1.237

6. Thota S, Kistangari G, Daw H, Spiro T. Immune thrombocytopenia in adults: an update. Cleve Clin J Med. 2012;79(9):641-650. doi:10.3949/ccjm.79a.11027

7. Thai LH, Mahévas M, Roudot-Thoraval F, et al. Long-term complications of splenectomy in adult immune thrombocytopenia. Medicine (Baltimore). 2016;95(48):e5098. doi:10.1097/MD.0000000000005098

8. Moulis G, Palmaro A, Montastruc JL, Godeau B, Lapeyre-Mestre M, Sailler L. Epidemiology of incident immune thrombocytopenia: a nationwide population-based study in France. Blood. 2014;124(22):3308-3315. doi:10.1182/blood-2014-05-578336

9. Poston JN, Gernsheimer TB. Management of immune thrombocytopenia in pregnancy. Ann Blood. 2021;6:5. doi:10.21037/aob-20-58

Reviewed by Hasan Avcu, MD, on 10/30/2022.

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